5 Things I Wish I Learned in Medical School about Managing Pain

With most medical schools devoting only a few curriculum hours to pain management training, many physicians begin their medical career underprepared to meet the needs of patients suffering with chronic pain. Here, Barry Cole, MD, identifies several key concepts that would help improve pain care in the US if only more physicians would learn about them sooner.

Pain is highly variable, personal, and cannot be managed with “blanket” order sets. How much someone hurts with a painful condition is based upon past pain experiences, understanding of the present pain circumstance, expectations and outcome, and may be colored by anxiety, depression, substance use/misuse, and more. Two people with similar accidents, injuries, surgeries, or medical conditions will have different intensities of pain. How much pain one tolerates is unique and variable, but not static. Thinking that a simple order set involving tramadol for mild pain, hydrocodone for moderate pain, and buprenorphine, fentanyl, hydromorphone, morphine, oxycodone, oxymorphone, and/or tapentadol for moderate to severe pain is naïve.

Pain medications are not all the same. There are many pain-relieving agents representing several different pharmacological groups. Starting at the periphery and working toward the CNS, there are topical anesthetics, capsaicin, and menthol products; to control inflammation there are non-steroidal and steroid-based anti-inflammatory agents; to modulate pain there are anti-depressants with mixed serotonin and norepinephrine mechanisms of action, anticonvulsants, and opioids. Within pharmacological groups there are differences relative to binding affinity, selectivity, tolerability, and side effect profile. Knowing more information about many types of medications is better than knowing a great deal about only a few medications.

No single practitioner should manage chronic, persistent pain without support. While those suffering from acute pain may be successfully managed by the efforts of a single practitioner, the needs of patients with chronic pain usually overwhelm their providers. More complicated patients are better managed by the efforts of several practitioners, using different skills, than by a single provider offering only prescription medications. Together, by reinforcing key messages and providing methods beyond simple, oral pharmacology, “team” efforts have been shown to be effective for those living with chronic pain.

There isn’t always someone to whom you may refer the “harder” patients. The myth of pain management and pain clinics is that they are plentiful, and readily available. Every practitioner should be minimally able to control pain, assess patients for their risk of opioid abuse and misuse, and understand what adjuvant medications can do to enhance the effectiveness of opioids. Open-ended prescriptions for opioids is not the answer, but rationing medications, delaying pain relief until some definitive pathology is identified, is equally wrong. Sharing the “blame” with an expert should be considered when initial strategies don’t work out, but expecting an anesthetic procedure to “cure” chronic pain is unrealistic. Referral to a multidisciplinary pain program is not the same as referring someone for an interventional procedure. Each has its role, but these approaches are not interchangeable.

Addiction is not always linked with physical dependence or tolerance. Most patients taking opioids, benzodiazepines, barbiturates, steroids, and other agents become tolerant at a cellular level, and wind up with physical dependence. Being physically dependent does not mean that someone is addicted (psychologically dependent), and not all of those who are addicted are physiologically dependent upon their substance of choice. Tolerance and physical dependence are expected with opioid therapy, but not opioid abuse, addiction, misuse, overdose, and withdrawal. We need to be very careful about the “word labels” we use, and strive for more linguistic precision rather than make broad judgments.

B. Eliot Cole, MD, MPA, FAPA, CPE, is a member of the Pain Management editorial advisory board. He has served in executive positions for several prominent pain management organizations and societies, including the American Society of Pain Educators and the American Academy of Pain Management. He has been a pain management fellow, clinician, educator, and advocate for nearly 30 years and has practiced in a variety of settings serving a wide range of patients.